Measurement of pressure walking in footwear used in leprosy

Pressure measurements were made on 10 leprosy patients while walking barefoot and while using 6 sample shoes. The sample shoes, which represented footwear currently used worldwide in leprosy programmes, included: 1, a USA extradepth shoe without insole; 2, a USA extradepth shoe with insole; 3, a Chinese tennis shoe; 4, a Mozambique sandal; 5, a Bombay sandal; 6, a Bombay sandal with rigid sole; and 7, the patients' prescribed footwear. Peak pressure was significantly lower while walking in all footwear, except with the extradepth shoe without an insole, when compared to barefoot walking. Peak pressure was significantly lower walking in the Bombay sandals, the Chinese tennis shoe, the extradepth shoe with an insert and the patients' prescribed shoe when compared to the extradepth shoe without an insert. Regression analysis showed a significant inverse relationship between pressure and insole thickness (P < 0.001, R2 = 0.17).     

Elderly persons' attitudes towards footwear--a factor in preventing falls

Injuries from falls are the main cause of trauma morbidity that leads to mortality among the elderly. One prevention strategy is to wear sturdy shoes. This study was undertaken to determine the attitudes towards and use of sturdy shoes among older adults. A random sample of persons ages 65 years and older was contacted by phone; 652 completed interviews. Sturdy shoes were worn by 26 percent of persons at the time of the call; more than two-thirds reported wearing such shoes at some time. Barriers to use of sturdy shoes included foot problems, difficulty putting them on, expense, style, and lack of knowledge about their importance. There was no difference in shoe use by the respondents' history of previous falls. The results provide information useful in the development of a program to increase the use of sturdy shoes by this population.     

Therapeutic footwear: enhanced function in people with diabetes and transmetatarsal amputation

OBJECTIVE: Patients with diabetes mellitus (DM) and a transmetatarsal amputation (TMA) have considerable deficits in function compared with age-matched controls. The purpose of this study was to determine if therapeutic footwear could improve the functional mobility of patients with DM and TMA. STUDY DESIGN: Repeated-measures design. SETTING: Academic medical center. PATIENTS: Thirty subjects (10 women, 20 men) with DM and a TMA, with a mean age of 61.7 +/- 4.0 yrs. INTERVENTIONS: Six types of footwear evaluating the following components: length of shoe (full-length or short shoe), a rigid rocker-bottom sole, and an ankle-foot-orthosis. OUTCOME MEASURES: Physical Performance Test (PPT), functional reach, and walking speed. Measurements in each footwear condition occurred after a 1-month adjustment period. RESULTS: Patients wearing full-length custom-made shoes with a total-contact insert, a rigid rocker-bottom sole or a short shoe with a rigid rocker-bottom sole (with or without an ankle-foot-orthosis) had similar and significantly higher scores in the PPT and faster walking speed than when wearing regular shoes with a toe filler (p < .05). The short shoe and the ankle-foot-orthosis, however, generated many patient complaints about cosmesis and restriction at the ankle, respectively. There were no differences in any of the measures of functional reach. CONCLUSION: Although there are individual exceptions, we recommend the full-length shoe, total-contact insert, and a rigid rocker-bottom sole for most patients with DM and a TMA.     

Circulating endothelin-1 in non-insulin-dependent diabetic patients with retinopathy

Chronic foot dermatitis can be disabling and footwear allergy is not always excluded as a cause, partly because patch testing to shoes and their components can be daunting. Once the diagnosis of shoe allergy is made, the difficult problem of finding suitable footwear remains. There is a lack of literature regarding the follow-up of these patients. We analysed the data on 55 patients with allergic contact dermatitis from their shoes and followed them up to see whether knowledge of the allergen had enabled them to find suitable footwear and to improve their dermatitis. The files of 55 patients with shoe allergy were analysed and 48 were followed up. Rubber was the commonest allergen, followed by chromate, p-tertiary-butylphenol-formaldehyde resin and colophony. All parts of the feet were affected, except the interdigital areas. The majority of patients suffered from hyperhidrosis. 43% were atopics, who had a super-added shoe allergy. The mean duration of the foot dermatitis before patch testing was 4 years 8 months. Follow-up of 48 cases showed that 87.5% had either improved or resolved completely. Most of our patients were successful in finding suitable footwear and many differing strategies were used. All patients with foot dermatitis which does not respond to treatment should be patch tested to exclude shoe allergy.     

A comparison of weightbearing pressures in various postoperative devices

Currently, there are a multitude of computerized gait analysis systems to evaluate weightbearing patterns in the foot. The following study utilizes the F-Scan System of foot pressure analysis. This system was applied to evaluate plantar pressures as they occur in various postoperative shoe gear and to determine which devices are most clinically beneficial in ambulatory surgery. A pressure sensor recorded plantar pressures in 20 feet wearing various types of postoperative shoe wear. Initially, a stockinette was used to simulate barefoot pressure, followed by a wooden postoperative shoe, a Darco postoperative shoe, a Darco closed postoperative shoe, a Darco "softie," a Darco wedge, an Equalizer Premium Walker, an Equalizer Low Top Walker, and an Aircast. The results demonstrated that the Equalizer Premium Walker was most efficient in reducing forefoot pressures, while the postoperative surgical shoes had variable results, noticeably with several increases in pressure being recorded.     

Running shoes for relief of plantar pressure in diabetic patients

There is a causal relationship between diabetic foot ulceration, elevated plantar pressure, and severe sensory neuropathy. Cushioned footwear intended to relieve plantar pressure is well established for prevention and healing of plantar ulcers. The aim of the present study was to investigate whether pressure relief by means of a running shoe with optimized forefoot pressure damping is comparable to that of a custom-made soft insole placed into an in-depth shoe. The in-shoe pressures were compared to an in-depth shoe with the original cork insole and with a leather-soled Oxford shoe. The maximum reduction of plantar pressure in the running shoe was 47% under the 2nd and 3rd metatarsal heads, 29% at the first metatarsal head, and 32% at the great toe in comparison to the Oxford shoe. This was surpassed only by the custom-made insole, which reduced pressures at the metatarsal heads by 50%. The specially designed running shoe yielded the same pressure relief at the central metatarsal heads as the custom-made insole. Such shoes are likely to be very useful in preventing diabetic foot ulceration in high-risk patients as a comparatively affordable and immediately available device.     

A comparative mechanical analysis of the pointe shoe toe box. An in vitro study

Dancing en pointe requires the ballerina to stand on her toes, which are protected only by the pointe shoe toe box. This protection diminishes when the toe box loses its structural integrity. The objectives of this study were 1) to quantify the comparative structural static and fatigue properties of the pointe shoe toe box, and 2) to evaluate the preferred shoe characteristics as determined by a survey of local dancers. Five different pointe shoes (Capezio, Freed, Gaynor Minden, Leo's, and Grishko) were evaluated to quantify the static stiffness, static strength, and fatigue properties (cycles to failure) of the shoes. Under axial loading conditions, the Leo's shoe demonstrated the highest stiffness level, and the Freed shoe exhibited the least strength. Under vertical loading conditions, the Leo's and Freed shoes demonstrated the highest stiffness levels, and the Gaynor Minden and Freed shoes exhibited the highest strength. Fatigue testing highlighted the greatest differences among the five shoes, with the Gaynor Minden demonstrating the highest fatigue life. Dancers rated the top five shoe characteristics, in order of importance, as fit, comfort, box/platform shape, vamp shape, and durability and indicated that the "best" shoe is one that "feels right" and permits artistic maneuvers, not necessarily the strongest or most durable shoe.     

Beckwith-Wiedemann syndrome: difficulties with prenatal diagnosis

The characteristics of the midsole were examined in four pairs of running shoes by a materials test. The variables of interest were the peak acceleration, time to peak acceleration and the kinetic energy absorbed. Ten subjects then ran at a recreational jogging pace (3.5 ms-1) barefoot and in the shoes. An accelerometer secured to the lower tibia was used to measure the peak acceleration and time to peak acceleration associated with footstrike. Subjects were also videoed and a kinematic analysis was undertaken at the knee and ankle joints. The results from the materials test showed that the shoes differed in their midsole characteristics, however, no significant differences (P > 0.05) were observed in the peak acceleration and time to peak acceleration during running in shoes. These variables were significantly greater in the barefoot running condition (P < 0.05), as compared with running in shoes. Small and subtle kinematic differences were observed between the barefoot and shoe conditions. It appears that the differences observed between the shoes in the materials test were not sufficient to elicit the kinematic changes observed between the barefoot and shoe conditions. It is suggested that runners operate within a 'kinetic bandwidth' when responding to impact stresses.     

Apical hypertrophy with massive myocardial fibrosis: comparison with electrocardiographic changes

RESEARCH QUESTION: Although gait patterns of children are well described in gait analysis studies for barefoot gait, loading patterns in gait with shoes have not been analysed compared to barefoot gait. METHODS: 30 children (age 1.8 to 4.8 years) were examined. Ground reaction forces were recorded using two series connected Kistler plates, taking the 3D coordinates and the time coordinate. The gait aspect was recorded using a video system. Three shoe types were tested against each other and against barefoot gait. RESULTS: 1399 gait cycles, 739 barefoot, 660 with shoes were usable for calculation. Statistic analyses comparing barefoot gait to gait with shoes showed: A significant increase in ground contact duration, a shifting of maximal load from the rear towards the midfoot area, a significant increased maximal load, a cushioning of the initial impact at primary ground contact. A comparison between the shoes showed no significant influence of a medial subtalar orthotic support. CONCLUSION: Shoes cause a significant change of loading patterns. But there are also significant differences between different shoe types. CLINICAL RELEVANCE: Shoes for children must provide a stabilisation for the hindfoot, and must not restrict motion in the areas of the ankle and the metatatrsophalangeal joints. The amount of load in the different gait phases must be considered for the construction of a dynamic shoe for children.     

Change in fibrinolytic activity as a parameter for assessing local mechanical stimulation during physical exercise

The influences of mechanical force during physical exercise on blood coagulation and fibrinolysis were investigated and the effects of sports equipment, especially shoes were also examined. As an experimental model, local mechanical vibration was applied to the palm of the hand. General coagulation parameters did not change, but fibrinolytic activity was elevated due to the tissue plasminogen activator (t-PA) released from vascular endothelial cells stimulated by vibration. The influence of mechanical stimulation by repeated side-jumping with bare feet was examined on the sole of the foot. As with t-PA, the von Willebrand Factor antigen (vWF:Ag) derived from vascular endothelial cells also tended to increase, but not as much as when wearing sports shoes. Sports shoes protected the blood vessels of the feet from damage by mechanical force during physical exercise. Changes in fibrinolytic activity and t-PA could be useful for assessing local mechanical stimulation during physical exercise and also as indexes for the development of new sports equipment and its improvement.     

Split anterior tibial transfer for spastic equinovarus foot deformity: retrospective study of 73 operated feet

The aim of this study was to describe the long-term results of split tibialis transfer in patients with stroke, cerebral palsy, and brain damage due to trauma, tumor, or infection. An evaluation was made of 73 feet in 69 patients with tendon transfer or lengthening for an average follow-up period of 44 months (range, 1 to 14 years). The primary indications for surgery included pain caused by pressure of the foot or toes on the floor or in shoes, ankle instability due to varus deformity, or difficulty wearing orthopedic shoes or braces chi(2) tests were used to compare preoperative and postoperative autonomy, and shoe and orthosis requirements. The results of this study include significant improvement in patient autonomy (p < 0.001), demonstrated by an improved ability to ambulate independently and a decreased need to wear orthopedic shoes (p < 0.001) and orthoses (p < 0.001), as well as an increased ability to wear normal shoes (p < 0.001). This procedure is safe and yields good results with minimal complications. The indications are very common, inasmuch as the number of young hemiplegic or tetraplegic patients surviving after a stroke or head injury is increasing. This procedure can result in definite improvement for these disabled patients and can increase their autonomy.     

An approach to averaging digitized plantagram curves

The averaging of outline shapes of the human foot for the purposes of determining information concerning foot shape and dimension within the context of comfort of fit of sport shoes is approached as a mathematical problem. An outline of the human footprint is obtained by standard procedures and the curvature is traced with a Hewlett Packard Digitizer. The paper describes the determination of an alignment axis, the identification of two ray centres and the division of the total curve into two overlapping arcs. Each arc is divided by equiangular rays which intersect chords between digitized points describing the arc. The radial distance of each ray is averaged within groups of foot lengths which vary by +/- 2.25 mm (approximately equal to 1/2 shoe size). The method has been used to determine average plantar curves in a study of 1197 North American males (Hawes and Sovak 1993).     

Sports medicine and rehabilitation. Surface and footwear

Load on the human body can be influenced by shoes and surfaces which is important both in sports and rehabilitation. The loading which can primarily be influenced are impact situations and friction as well as the stability of the foot. This stability is of main interest in the prevention of pain and injury. However, a certain amount of loading is necessary to improve strength and structure of biological materials. In the past, the development of shoe and surface materials has hardly been perceived under this aspect, but may be increasingly important in the future.     

Ethics in clinical research: searching for absolutes

Recently botulinum toxin has been used with increasing frequency as a safe and effective treatment for many previously refractory conditions associated with excessive muscle activity. The indications for use of botulinum toxin injection continue to expand. This report describes the case of an 83-year-old woman with a history of diabetes mellitus and lumbar spinal stenosis who developed a severe focal dystonia of the left great toe, such that the toe maintained the extended position. Functionally, the resultant deformity prevented the patient from wearing shoes. In addition, the patient had significant pain in the left great toe. Under needle electromyographic localization, 50 units of botulinum toxin were injected into the left extensor hallucis longus muscle. Two weeks after the injection the patient was symptom free and could place her left foot into a shoe. Seven months later, she remained symptom free. This case illustrates that localized injection of botulinum toxin to a specific lower limb muscle can effectively result in decreased muscle activity and functional improvement.     

Cytokine induction of platelet activation

A three-dimensional, two-part model of the foot, for use in a simulation of human gait, is presented. Previous simulations of gait have not included the foot segment (e.g. Siegler et al., 1982, J. Biomechanics 15, 415-425) or have fastened it to the ground (e.g. Onyshko and Winter, 1980, J. Biomechanics 13, 361-368). A foot model based on viscoelastic elements (e.g. Meglan, 1991, Ph.D. thesis, Ohio State Univ.), allows more freedom of movement and thus models the physical system more closely. The current model was developed by running simulations of the foot in isolation from just before heel contact to just after toe-off. The driving inputs to the simulation were the resultant ankle joint forces and moments taken from a gait analysis. Nine linear, vertically oriented spring/damper systems, positioned along the midline of the foot were used to model the combined viscoelastic behaviour of the foot, shoe and floor. Associated with each vertical spring/damper system were two orthogonally placed, linear, horizontal dampers used to provide the shear components of the ground reaction force. Torques at the metatarsal-phalangeal joint were supplied by a linear, torsional spring and damper. Control about the vertical axis and the long axis of the foot was achieved by the use of linear, torsional dampers. The predicted kinetic and kinematic values are very similar to those taken from the gait analysis. The model represents an improvement over previous work because the transition from swing to stance was smooth and continuous without the foot being constrained to any specific trajectory.     

Theatre footwear: a health hazard?

Theatre footwear frequently appears to be contaminated with blood. We assessed objectively the nature and degree of contamination of theatre shoes after cleaning. Two hundred pairs of theatre shoes were randomly selected from three hospitals in South East Wales. Hospital 1 (H1), 100 pairs of shoes, Hospital 2 (H2), 40, Hospital 3 (H3), 60. They were examined for general appearance, the presence of bacterial pathogens and blood, using a leuchomalachite green assay. The majority of shoes were dirty, 63% in H1, 80% in H2, and 95% in H3. Six per cent of shoes in H1, 2.5% in H2 and 0% in H3 were contaminated with staphylococcus aureus. No shoes were contaminated with pseudomonas aeruginosa. Thirty six per cent of shoes in H1, 40% in H2 and 57% in H3 were contaminated with blood. In H1 it was possible to determine the grade of staff to whom the shoes belonged. Fifty eight per cent of consultant surgeons' shoes tested positive for blood, 50% of junior surgeons, 16% of operating department assistants and none of nurses' theatre shoes. The high level of blood contamination following cleaning may pose a potential HIV or hepatitis B risk to patients, manual shoe cleaner and surgeons. We have demonstrated that current shoe cleaning practices are ineffective. We propose methods that should eliminate this risk. Procedures will need to be defined.     

Evidence for the HIV-1 phenotype switch as a causal factor in acquired immunodeficiency

To assess the short- and long-term psychosocial effects of wearing modified shoes during childhood, we compared measures of self-esteem and self-image of 46 adults who wore shoe modifications during childhood with 92 adult controls. The treated cases characterized their remembrance of the experience through a subjective report questionnaire. Those who wore shoe modifications during childhood showed lower self-esteem than controls (p < 0.05). In addition, the treated recalled a decrease in their self-image (41%), the experience as negative (57%), being teased about their footwear (47%), and having their activities limited (41%). These findings show that wearing shoe modifications during childhood, in addition to being ineffective and unnecessary as demonstrated in prior studies, is a negative experience in childhood and is associated with lower self-esteem in adult life. Such data suggest that children who wore modified footwear may fall into the spectrum of the vulnerable child syndrome.     

The diabetic foot. Optimal prevention and treatment can halve the risk of amputation

Almost half of all lower leg amputations are performed in patients with diabetes. In over 70 per cent of these cases, amputation is precipitated by progression of foot ulceration to deep gangrenous infection. Most foot ulcers are preceded by trauma, usually due to ill-fitting shoes, and are precipitated by sensory motor neuropathy with varying degrees of peripheral vascular disease. The Swedish Medical Research Council and the Swedish Institute for Health Services Development arranged a conference on diabetic foot problems in April 1998, the purpose of which was to arrive at a consensus regarding the prevention and management of diabetic foot. It was concluded that a satisfactory multidisciplinary approach should include regular control of feet and footwear, preventive foot care (education, footwear, chiropody), continuous follow-up of high-risk feet, and early recognition of revascularisation. Continuous registration of amputation, irrespective of type, cause and site, might substantially reduce the amputation rate among diabetics. Were such an approach to reduce the incidence of diabetes-related amputation by 50 per cent, annual costs for the management of diabetic foot in Sweden would be reduce by SEK 400 million (the value of improved quality of life not taken into consideration).     

Plantar foot pressures during treadmill walking with high-heel and low-heel shoes

The effect of walking with high-heel shoes on plantar foot pressure distribution was investigated. Ten normal women walking in shoes with low heels were compared to women walking in high-heel shoes. It was shown that high-heel shoes increased the load on the forefoot and relieved it on the hindfoot. The load passed toward the medial forefoot and the hallux. The lateral side of the forefoot showed a decrease in contact area, reduced forces, and peak pressures. The medial side of the forefoot had a higher force-time and pressure-time integral. It is suggested that these higher loads on the medial forefoot may aggravate symptoms in patients with hallux valgus deformity.